Lifeline Applicant. Please return the completed application & fee to: Simi Valley Hospital Lifeline Program 2975 N. Sycamore Dr. Simi Valley CA 93065

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1 Lifeline Applicant Please return the completed application & fee to: Simi Valley Hospital Lifeline Program 2975 N. Sycamore Dr. Simi Valley CA You must have a landline phone (not just a cell phone) in order to get Lifeline. "#$%&"'()*+$,-./01(2$3&"432*+$5067$89:17;<.0$3<=0><?0477><@A/<-?B"-C012D00/EF GH

2 "#$%&&'()*+(,*-(./$0/12 "#$%&'$(&)$*+$,-$)./0$123)1$4,3-,5+& )&7/1$,8&.$2,38&9$9:/;&+&<5(($/=312&75(>"#$ 2(5.&)-5.5(('3,#$(2&'5'5((&19$7$.7$95)9/36.5)I7261#/36,:6773):$.561$/365,$9&13,&$)7$9A &++3:&(&J$93,6).3)1.&361>;&+&<5(($/=312&75(&15:($733''$,7#$'&)$175)9)$H$17&)7$.#)3(3-/73 7#31$H$1$,8$> "#$%&'#()$&*(+$#()&#&,#(-../($0(01%%*2(30(14%&5(6$"(*7$"%)(1%816*(9'&**(6$"'(4"##$+(87&+(6$"(+&&)(7&%92( For information and an application 3$4&$"55,6 Call the Lifeline office at (805) or Visit the Simi Valley Senior Center located at 3900 Avenida Simi, Simi Valley, CA or Go to the hospital s website at and click on Lifeline Program under the Information For column at the bottom left side of the page. The units are provided on an as-available basis at a reduced monthly cost to eligible seniors. If an applicant has low or very low income, according to HUD guidelines, the cost is $15 for participation in the Lifeline Program. Those applicants whose income exceeds the HUD guidelines will pay a modest fee of $30 per month. The Auto-Alert option is an additional monthly cost of $10. If you cannot afford participation in the Lifeline Program, Simi Valley Hospital may be able to help.

3 APPLICATION FOR THE LIFELINE PROGRAM Name Home Phone Number Address City State Zip Cell Phone Number address Another person who can provide additional information: Name Relationship Phone(s) Who told you about the Lifeline Program? Relationship: Phone: What is your date of birth? How many people are in your household? _ Do you use a cane? Yes No Do you use a walker? Yes No Do you use a wheelchair? Yes No Can you walk without help? Yes No Do you Speak English? Yes No If not, what language are you fluent in? Do you own your home or rent? Do you receive help at home for cooking, housework, or personal care? Specify 3 "#$%&"'()*+$,-./01(2$3&"432*+$5067$89:17;<.0$3<=0><?0477><@A/<-?B"-C012D00/EFGH

4 Do you receive services provided by a Social Services Program? Yes No_ Name of Program? Do you have any physical disabilities? Yes No If yes, please describe. Have you seen a doctor recently for ongoing medical problems? Yes No Please give details. Have you had a medical emergency recently that required help? Yes No _ Please give details. Why do you want a Lifeline Home Communicator Machine? 4 "#$%&"'()*+$,-./01(2$3&"432*+$5067$89:17;<.0$3<=0><?0477><@A/<-?B"-C012D00/EFGH

5 RESPONDER INFORMATION-REQUIRED FOR LIFELINE PROGRAM You will need three responders who can help you if there is an emergency. These should be people who live within a short travel distance of your home. Please fill in the following blanks: Responder # 1: Name: Home phone: Work phone: Cell phone: address Address: _ City: State: Zip: _ Responder # 1 is: a relative; or a neighbor; or a friend (If a relative-how related ) Do they have a key: _ Responder # 2: Name: Home phone: Work phone: Cell phone: address Address: _ City: State: Zip: _ Responder # 2 is: a relative; or a neighbor; or a friend (If a relative-how related ) Do they have a key: _ Responder # 3: Name: Home phone: Work phone: Cell phone: address Address: _ City: State: Zip: _ Responder # 3 is: a relative; or a neighbor; or a friend (If a relative-how related ) Do they have a key: _ Nearest Relative: Name: Home phone: Work phone: Cell phone: address Address: _ City: State: Zip: _ Primary Care Doctor: Office phone: Address: _ City: State: Zip 5 "#$%&"'()*+$,-./01(2$3&"432*+$5067$89:17;<.0$3<=0><?0477><@A/<-?B"-C012D00/EFGH

6 Additional Information required: Do you have caller ID or call screening on your phone? Yes _No Do you have more than one phone line? Yes No _ Do you have a computer? Yes No Do you have a DSL computer phone line? Yes No Does your phone operate through your computer (VOIP system)? Yes No _ Lifeline units (subject to availability) are provided at a discounted rate to seniors who meet the Low or Very Low HUD income criteria. There is a one-time $10 data entry fee required for each application for Lifeline service. I am a low-income senior and will provide the following information to determine my eligibility for a $15 monthly cost machine: I am a single, female head of household: Yes No I am a single, male head of household: Yes No The gross annual income for my total household is: $ _ (Attach a copy of last year s tax form or two recent bank statements to verify total household income) OR I understand and am willing to pay $30 per month for Lifeline service. (I will receive in the mail monthly an invoice and a self addressed envelope to make my payments.) 6 "#$%&"'()*+$,-./01(2$3&"432*+$5067$89:17;<.0$3<=0><?0477><@A/<-?B"-C012D00/EFGH

7 HUD requires that all organizations allocated CDBG funds collect race and ethnicity data. RACE Select One and White Black/African American Asian American Indian/Alaskan Native Native Hawaiian/Other Pacific Islander American Indian or Alaskan Native AND White Asian AND White Black/African American AND White American Indian/Alaska Native AND Black/African American Other Hispanic Ethnicity (If applicable) The City of Simi Valley is only supplying to Simi Valley Hospital the names of persons requesting installation and use of the Lifeline machines and the applicant acknowledges, by signing this form, that the City does not assume any liability or responsibility for any damage, injury or death which may be caused by the supplying or non-supplying of any home communicator equipment or by any failure of the equipment or any act or omission relating to performance of any services by the hospital. The applicant hereby agrees to indemnify, hold harmless and defend the City of Simi Valley, Members of its City Council, its officials, officers, boards, commissions, agents, and employees against all claims, suits, losses, damages and costs, including, but not limited to, court costs and reasonable attorneys' fees, on account of any injury or damage, including death, incurred by applicant or anyone else as a result of the supplying, non-supplying, operation or non-operation of any equipment or any act or omission relating to the performance of service by the hospital. I have read and understand the hold harmless clause. I also certify that the foregoing application information is true and accurate to the best of my knowledge. Signature (Must be signed by subscriber) Date Please return to: Simi Valley Hospital Lifeline Program 2975 N. Sycamore Dr. Simi Valley, CA "#$%&"'()*+$,-./01(2$3&"432*+$5067$89:17;<.0$3<=0><?0477><@A/<-?B"-C012D00/EFGH

8 Lifeline Application Instructions Check off each item and return list with your application Be sure to sign your application on page 7 Print all information clearly Attach one of the following: A copy of your prior year s income tax form Or copies of two recent bank statements showing your sources of income Or a copy of your social services intake form If more than one person lives in your household, be sure income information is for all members Provide the complete names, addresses, and all phone numbers for each of your three responders on page 4 Attach $10.00 date entry fee (one-time fee). Please make checks payable to Simi Valley Lifeline Return to: Simi Valley Hospital Lifeline Program 2975 N. Sycamore Dr. Simi Valley CA For questions, please call: "#$%&"'()*+$,-./01(2$3&"432*+$5067$89:17;<.0$3<=0><?0477><@A/<-?B"-C012D00/EFGH